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Characteristics of Children with Acute Rheumatic Carditis from a High-Incidence Region: Importance of Unexplained
Rajiv Narang1, Anita Saxena2, Sivasubramanian Ramakrishnan1
1Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.
Insights
Acute rheumatic carditis (ARC) in children often doesn't meet diagnostic criteria. Key indicators include worsening dyspnea, young age, mitral regurgitation, echocardiographic nodules, and elevated C-reactive protein (CRP).
Area of Science:
- Pediatric Cardiology
- Rheumatology
- Public Health
Background:
- Acute rheumatic fever (ARF) and acute rheumatic carditis (ARC) remain significant global health issues, particularly in developing nations.
- Understanding the specific characteristics of children with ARC is crucial for effective management and public health strategies.
Purpose of the Study:
- To investigate the clinical and echocardiographic features of children diagnosed with acute rheumatic carditis (ARC) at a tertiary care center.
- To evaluate the applicability of diagnostic criteria in this patient population.
Main Methods:
- A retrospective study of 126 children diagnosed with ARC.
- Data collection included clinical presentation, symptoms, laboratory results (ASO titres, CRP, ESR), modified Jones criteria assessment, and echocardiographic findings.
- Echocardiography assessed valve morphology, regurgitation severity, and left ventricular function.
Main Results:
- The study identified common symptoms like dyspnea (48%) and heart failure (21%), with only 2.4% showing subcutaneous nodules and none with erythema marginatum or chorea.
- Diagnostic criteria were met in only 46% of cases, highlighting potential limitations in current diagnostic guidelines.
- Echocardiography revealed significant mitral valve thickening (77%) and mitral regurgitation (95%, severe in 78%), with nodules observed on valve leaflets in 43% of patients.
Conclusions:
- The modified Jones criteria may not be fully satisfied in children being treated for ARC.
- Indicators such as recent dyspnea, younger age, severe mitral regurgitation, echocardiographic nodules, and elevated CRP are vital for diagnosis and management.
- Further refinement of diagnostic criteria for ARC in children is warranted.
Background:
Acute rheumatic fever (ARF) and acute rheumatic carditis (ARC) continue to be a major public health problem in developing countries.
Objective:
To study the characteristics of children with ARC being treated at a tertiary centre.
Methods And Results:
We studied 126 children (mean age 10.4 ± 2.3 years, range 5-15 years, 60% males) diagnosed with ARC by treating cardiologists. Most had lower socio-economic status. Fifty of 126 (40%) presented with a first episode of ARC. Joint symptoms were present in 29% and fever in 25%. Only 2.4% had subcutaneous nodules and none had erythema marginatum or chorea. Fifty-one percent presented in NYHA class II and 29% in NYHA class III or IV. Tachycardia and heart failure were present in 53% and 21%, respectively. Recent worsening of NYHA class (dyspnoea) was the commonest feature (48%). Laboratory investigations showed raised antistreptolysin O titres (>333 units) in only 36.7% of patients. Raised C-reactive protein (CRP) was present in 70%, while raised erythrocyte sedimentation rate was found in only 37% of patients. On the basis of above findings, the modified Jones criteria (2015) for the diagnosis of ARF were satisfied only in 46% of children. Echocardiography showed mitral valve thickening in 77% and small nodules on the tip of the leaflets in 43% (27 and 8%, respectively for aortic valve). Left ventricular ejection fraction was <50% in only 3 patients. The dominant valve lesion was mitral regurgitation (MR) (present in 95% of patients; severe in 78%, moderate in 15%), while aortic regurgitation was present in 44% (severe in 14%).
Conclusions:
The criteria are often not satisfied by patients being treated for ARC. Recent unexplained worsening of dyspnoea, young age, significant MR, echocardiographic nodules, and elevated CRP are important indicators.
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